GORD + Oesophageal Disorders Flashcards
What is GORD?
Gastro-oesophageal reflux diease
A common disease caused by reflux of the stomach contents (acid +/- bile) causing troublesome symptoms and/or complications
What is the pathophysiology of GORD?
Reflux occurs due to:
- More frequent Transient Lower Oesophageal Sphincter Relaxations (TLESRs)
- Failure of intra-abdominal segment of the oesophagus which acts as a flap valve
- Failure of mucosal rosette formed by folds of the gastric mucosa and the contraction of the crural diaphragm at the LOS
- Reduced oesophageal motility
What is the main cause of reflux in GORD?
LOS relaxes transiently independently of swallow after meals
What are oesophageal mucosal defence mechanisms?
- Mucus - traps bicarb which acts as a buffer
- Epithelium - structure limits diffusion of H+ into cells
- Sensory mechanisms - pain due to irritation by acid and contraction of longitudinal muscles
What are the main causes of GORD?
- LOS hypotension
- Hiatus hernia
- Oesophageal dysmotility
- Obesity
- Gastric acid hypersecretion
- Delayed gastric emptying
- Smoking
- Alcohol
- Pregnancy
- Drugs
What are the different types of hiatus hernia?
- Sliding hiatus hernia
- Rolling hiatus hernia
What is a sliding hiatus hernia?
The GO junction slides up into the chest. ACid reflux often happens as the LOS becomes less competent in many cases
What is a rolling hiatus hernia?
The GO junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus. As the GO remains intact, GORD is less common
Which type of hiatus hernia is more commonly associated with GORD?
Sliding hiatus hernia
What lifestyle factors play a role in the development of GORD?
- Smoking
- Alcohol
- Obesity
- Hot beverages
- Caffeine together with patient age and gender.
What are symptoms of GORD?
- Dyspepsia
- Belching
- Acid brash
- Waterbrash
- Odynophagia
- Nocturnal asthma/Chronic cough
- Laryngitis
- Sinusitis
What is dyspepsia?
Burning, retrosternal discomfort after meals, lying down, stooping. It can be relieved by antacids
What is acid brash?
Acid or bile regurgitation
What is waterbrash?
Markedly increased salivation
What is adynophagia?
Painful swallowing - can be caused by oesophagitis or ulceration
What are complications of GORD?
- Oesophagitis
- Ulcers
- Benign stricture
- Iron-deficiency
- Barrett’s oesophagus
What might your differential diagnosis be for someone presenting with features of GORD?
- Oesophagitis from corrosives
- NSAIDs
- Duodenal/Gastric ulcers
- Gastric cancer
- Non-ulcer dyspepsia
- Oesophageal spasm
- Cardiac disease
If someone presented with features of GORD, what investigations would you consider doing?
Primarily clinical diagnosis. If dysphagia, or >55 yrs with alarm symptoms:
- Endoscopy
- 24-hr intramural pH monitoring/impedence +/- manometry
What can endoscopy show in someone with features of GORD?
- Oesophagitis
- Hiatus hernia
- Barrett’s oesophagus
What is involved in pH monitoring?
24-hour ambulatory monitoring uses a pH-sensitive probe positioned in the lower oesophagus and is used to identify acid reflux episodes (pH <4). Catheter and implantable sensors are available; both are insensitive to alkali.
pH is a valuable means of correlating episodes of acid reflux with patient’s symptoms.
What is involved in impedance monitoring?
Uses a catheter to measure the resistance to flow of ‘alternating current’ in the contents of the oesophagus. Combined with pH it allows assessment of acid, weakly acid, alkaline and gaseous reflux, which is helpful in understanding the symptoms that are produced by a non-acid reflux.
What is manometry?
Performed by passing a catheter through the nose into the oesophagus and measuring the pressures generated within the oesophagus.
It is used to assess oesophageal motor activity. It is not a primary investigation and should be performed only when the diagnosis has not been achieved by history, barium radiology or endoscopy.
What is defined as excessive reflux on pH testing?
pH < 4 for > 4% of the time + correlation with symptoms
What lifestyle factors would you address when managing someone with GORD?
- Weight loss
- Smoking cessation
- Small, regular meals
- Avoid eating < 3 hrs before bed
-
Reduce
- Hot drinks and alcohol
- Citrus fruits
- Spicy food
- Caffeine
- Chocolate
What medications would you consider givign someone who was suffering from GORD?
In order
- Antacids - Gaviscon, magnesium trisilicate mixture
- PPI - lansoprazole, omeprazole
- H2 blockers
What drugs would you want to avoid in someone with GORD?
Affecting oesophageal motility
- Nitrates
- Anticholinergics
- CCBs
Causing mucosal damage
- NSAIDs
- K+ Salts
- Bisphosphonates